Medicare Access and CHIP Reauthorization Act: The Final Rule

The Medicare Access and CHIP Reauthorization Act represents the biggest change in medicine that I’ve witnessed in my career…. We should seize the opportunity to transform how care is provided from a system we know is broken to one that truly represents quality and value. It’s too good an opportunity to miss.

— Philip J. Stella, MD

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It is gratifying to see the Centers for Medicare & Medicaid Services (CMS) does listen to public comments regarding new proposals. Since CMS opened the comment period for its Quality Payment Program, which repeals the Sustainable Growth Rate Formula and was proposed to implement the Medicare Access and CHIP Reauthorization Act of 2015 ­(MACRA), ASCO has provided extensive feedback to CMS on important issues for our members.

What We Know

The final rule on the Quality Payment Program that was released on October 14, 2016, reflected much of the feedback from ASCO and other provider organizations. Here is what we know so far:

• The Quality Payment Program offers more flexibility in participating and meeting the reporting and performance standards to avoid negative payment adjustments and receive positive adjustments or bonuses in the first year of program implementation. In 2017, clinicians have three options for participation in the Merit-Based Incentive Payment System. First, a practice may avoid a negative payment adjustment in 2019 simply by reporting on one measure in the 2017 performance year. Second, clinicians may report on measures for as few as 90 days and receive a small positive adjustment. Third, clinicians may report for the full year and receive a positive adjustment.

• For the 2017 performance year, CMS excluded cost (resource use) from the composite score calculation. In 2017, clinicians will only be required to score on Quality, Advancing Care Information (Meaningful Use), and Improvement Activities (Clinical Practice Improvement Activities). Cost will be added back the following years and may comprise up to 30% of the composite score. CMS will still collect claims data, and assess performance in the cost category in 2017. However, clinicians will not be scored in 2017.

To get an idea of their resource use, practitioners should look at their Quality and Resource Use Report, available from CMS. For now, the Quality Payment Program still includes all resource use incurred by a patient attributed to a particular clinician, including Medicare Parts A and B as well as Part B drugs. ASCO has vehemently opposed including drugs in the clinician’s resource use, on the basis that oncologists have very little control over the price of drugs, many of which have no lower-cost therapeutic equivalents. Rather, we have proposed other methodologies like appropriately developed clinical pathways to better assess appropriate resource use.

• Quality reporting for the Merit-Based Incentive Payment System now includes a General Oncology Measures Group with 19 oncology-related quality measures to choose from. Many of these measures are currently included in the Quality Oncology Practice Initiative (QOPI®) measures. The Merit-Based Incentive Payment System will require quality reporting on 50% of eligible patients. The ASCO QOPI reporting registry is being redesigned to allow electronic data collection to meet this requirement for 2018 ­reporting.

• Practices participating in Advanced Alternative Payment Models will be exempt from the Merit-Based Incentive Payment System.CMS has designated the Oncology Care Model pilot as an Advanced Alternative Payment Model if there is two-sided risk. Practices participating in the Oncology Care Model may amend their contracts and commit to accepting upside and downside risks as early as 2017.

By the Advanced Alternative Payment Model, Oncology Care Model practices will get a 5% lump sum bonus and will be exempt from the Merit-Based Incentive Payment System. Practices participating in the one-sided risk Oncology Care Model do not have to report on quality since this is already built into the model. In addition, participating in an Oncology Care Model earns clinicians 100% of their total Clinical Practice Improvement Activities points.

It’s clear that Medicare wants to shift more practices over time to the Advanced Alternative Payment Model, and I believe the Oncology Care Model gives us a window into CMS’s thinking. ASCO is currently developing an alternative to the Oncology Care Model based on the Patient-Centered Oncology Payment model, which will include active management of patients in defined episodes of care. Stay tuned.

• CMS has launched an excellent website for the Quality Payment Program, which can be found at https://qpp.cms.gov.

What We Need to Know

Here is what we still don’t know and will be seeking further clarification and direction on in the 60-day comment period:

• What constitutes an episode of care for measuring the cost of cancer care in the Merit-Based Incentive Payment System? How can CMS truly compare one practice to another regarding cost with only claims data? Depending on stage and molecular profile, treatment of patients with the same ICD10 codes may vary markedly on cost.

• Will Medicare Part D be included in the assessment of drug costs in the future?

• What certification is needed to qualify as an Oncology Medical Home? The American College of Surgeons and the National Committee for Quality Assurance have excellent programs that many practices have embraced.

• What changes are necessary to adapt the Patient-Centered Oncology Payment model for use as an Advanced Alternative Payment Model?

ASCO will continue to work with CMS to answer these questions as the program evolves.

Seizing the Opportunity

The Medicare Access and CHIP Reauthorization Act represents the biggest change in medicine that I’ve witnessed in my career. Documentation may seem onerous and costly, but whether with Merit-Based Incentive Payment Systems or Advanced Alternative Payment Models, MACRA is here to stay. Complaining won’t help, but we should seize the opportunity to transform how care is provided from a system we know is broken to one that truly represents quality and value. It’s too good an opportunity to miss.

ASCO remains committed to helping our members succeed. We will be providing an initial response to the final rule, and, in 2017, we will work diligently with CMS to answer the above questions and provide the tools our members need.

It is incumbent on all of us to be informed and prepared. ASCO has developed multiple educational opportunities to help with the transition to the MACRA value-based reimbursement system, including webinars, workshops, and meetings. Take advantage of these offerings.